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Subject:  For profit insurance: another horror story Date:  6/20/2013  4:21 PM
Author:  salaryguru Number:  50251 of 116906

Back in March when SGSpouse and I were still struggling to understand what was happening to her, we went to the emergency room one night. Her neck was in incredible, continuous pain. She had not been able to sleep for a couple of nights and was unable to do anything but lie down and ache.

She had gotten a preliminary diagnosis of lupus only days earlier. (It turned out not to be lupus, but a closely related auto immune disease, MCTD. We didn't know that at the time.) She didn't think the neck pain was likely to be the "lupus" because previously, the "lupus" flare-ups had only been in her knees and shoulders. This was different. For a couple of days she kept hoping this was an unrelated neck pain that would go away if she rested. But it didn't go away. It got worse.

Finally, during the second night of agony, I convinced her to let me take her to the emergency room so see if they could offer at least some pain relief that would allow her to sleep. Maybe they would even be able to find and treat the root cause. We tried to call our insurance company prior to and during the emergency room visit, but we could not get through to a human. No one answered or we got recorded messages.

We spent a little over 5 hours in the emergency room. The emergency room doctor felt certain that this was not related to our recent lupus diagnosis. He tested her for meningitis. He ran some other general blood tests. One thing that troubled me is that he did not seem to take the swelling and tenderness in her neck as a serious problem. He seemed to doubt that she really was in that much pain. He eventually dosed her with morphine and a muscle relaxant. The pain remained. So he increased the morphine and gave her a second dose. This finally put her to sleep. I paid for the visit and took her home.

But the next day, the pain was back worse than ever. We went to our new Rheumetolgist. He agreed that the emergency room doctor should have tested for meningitis but also was surprised that he didn't see how badly her neck was swollen or appreciate the tenderness. He gave her a direct injection of prednisone and told her to take prednisone for 5 days according to a specific schedule. There was significant immediate relief followed by greater comfort each day. After three days the pain was gone.

Now the billing starts. . . The hospital code used for the diagnoses is listed to mean "stiff neck". The insurance company says that "stiff neck" is not a valid emergency room illness. Here's why this matters. The negotiated insurance rate for the visit and treatment is a little over $1000 - which I have already paid since we have a high deductible policy. But if the insurance company declares the treatment invalid, then the non-insured cost of the emergency room visit is over $6000. Note that the insurance company does not pay one dime either way. The hospital was originally happy with my payment. But now, they want me to pay more if the insurance company denies the claim - a claim that is in question because of the code their doctor put on the paperwork.

I remind you, this happened in March. We, the hospital and the insurance company have been dealing with this for over 3 months and there is no sign of sanity breaking out at either the hospital or the insurance company.

Honestly, I would ignore the whole thing until someone threatens to take up some action against us. I'm not paying over $5000 because an emergency room doctor was unable to diagnose a real problem and used an 8 digit code that the insurance company doesn't like. But SGSpouse sees this like a kid sees a scab. She wants it solved. Now. So she calls up the hospital and insurance company and tries to rationalize with them. You can guess how that goes.

But this whole thing really does reveal some of the massive inefficiencies that our teabagger approved for-profit health insurance system has. If we had a single payer system this entire nightmare would likely never happen. One payer. One billing system. No need for an army of accountants and underwriters at every healthcare facility and insurance company in America. No reason for this massive inefficiency and bureaucratic insanity.
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